INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on July 24, 2023 through July 25, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocate, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of one applicable personnel record reviewed.
Employee # 6 was hired as a counselor on May 31, 2022 and was due to have TB/STD training no later than May 31, 2023. The TB/STD training was not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have designated a support staff member to oversee trainings for the staff. A spreadsheet has been created to track required trainings and applicable timeframes for completion. Staff member #6 has been scheduled for the required TB/STD training. Moving forward, staff will be scheduled early in their tenure with AMHA to ensure that they complete the required trainings within their first year of employment. The Program Director will be responsible for overseeing that this is done. |
715.9(b)(2) LICENSURE Intake
(b) Exceptions to the requirements in subsection (a) are:
(2) Upon readmitting a patient who has been out of a narcotic treatment program for 6 months or less after a voluntary termination, the narcotic treatment program shall update the information in and review the patient 's file to show current opiate narcotic dependency, but need not conduct a physical examination and applicable laboratory tests. Privileges earned during the previous treatment may be reinstated at the discretion of the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to update information in and review the patient's file to show current opiate narcotic dependency in one of one applicable readmitted patient record reviewed.
Patient # 2 was readmitted to the facility on December 7, 2022 and was still active at the time of the inspection. The patient received their first dose of methadone on December 7, 2022; however, the current opiate narcotic dependency was not documented in the patient record until December 13, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director discussed this finding with the Medical Director. The physicians have been reminded to complete and sign the required Physician's Documentation of Opiate Dependence form on the day of intake, prior to the patient's first dose of methadone. We will monitor this via our quality record management and discuss in our Quality Assurance committee meetings. The Medical Director will be responsible for oversight. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month, 1 hour of which shall be individual psychotherapy, during each patient's first 2 years in treatment in one of three applicable patient records reviewed.
Patient # 4 was admitted on March 2, 2022 and was discharged on January 20, 2023. The record of service and progress notes documented that during the month of November 2022, there was 30 minutes of psychotherapy provided to the patient.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
This finding was reviewed with the management team and a meeting with clinical staff is scheduled for 8/2/23 to discuss. As part of our Quality Assurance committee's Quality Record Management activities, we will monitor compliance with required minimum psychotherapy hours. During individual supervision, we will review and discuss individual patients who may be at risk for not meeting required hours early enough in the month so necessary steps can be taken prior to the end of the month. We will continue to work with staff on patient engagement strategies. The Clinical Program Manager will be responsible for oversight of these tasks. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in five of seven applicable client records reviewed.
Client # 1 was admitted on February 1, 2023 and was still active at the time of the inspection. A treatment plan update was completed on March 2, 2023 and the next update was due no later than May 2, 2023; however, the update was not completed until May 10, 2023.
Client # 2 was admitted on December 7, 2022 and was still active at the time of the inspection. A treatment plan update was completed on April 16, 2023 and the next update was due no later than June 16, 2023; however, the update was not completed until June 22, 2023.
Client # 3 was admitted on August 23, 2018 and was still active at the time of the inspection. A treatment plan update was completed on February 15, 2023 and the next update was due no later than April 15, 2023; however, the update was not completed until May 2, 2023.
Client # 5 was admitted on September 22, 2022 and was discharged on April 11, 2023. The individual treatment and rehabilitation plan was completed on October 25, 2022 and the first update was due no later than December 25, 2022; however, the update was not completed until April 5, 2023.
Client # 6 was admitted on October 11, 2006 and was discharged on January 9, 2023. A treatment plan update was completed on August 3, 2022 and the next update was due no later than October 3, 2022; however, the update was not completed until November 1, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This finding was reviewed with the management team and a meeting has been scheduled with the clinical staff to discuss on 8/2/23. We will re-train staff on the timely completion of treatment plans which includes signing the document on the day it was completed. We will monitor treatment plan completion as part of Quality Assurance committee's Quality Record Management activities and discuss findings in our bi-monthly meetings. During individual supervision, the clinical supervisors will address specific concerns related to timely completion of the treatment plans. The clinical Program Manager will be responsible for oversight of these activities. |